Thread: Study Says Cortisone Bad In The Long Haul

http://well.blogs.nytimes.com/2010/1...-things-worse/

http://www.thelancet.com/journals/la...160-9/abstract

...a major new review article, published last Friday in The Lancet, should revive and intensify the doubts about cortisone’s efficacy. The review examined the results of nearly four dozen randomized trials, which enrolled thousands of people with tendon injuries, particularly tennis elbow, but also shoulder and Achilles-tendon pain. The reviewers determined that, for most of those who suffered from tennis elbow, cortisone injections did, as promised, bring fast and significant pain relief, compared with doing nothing or following a regimen of physical therapy. The pain relief could last for weeks.

But when the patients were re-examined at 6 and 12 months, the results were substantially different. Overall, people who received cortisone shots had a much lower rate of full recovery than those who did nothing or who underwent physical therapy. They also had a 63 percent higher risk of relapse than people who adopted the time-honored wait-and-see approach. The evidence for cortisone as a treatment for other aching tendons, like sore shoulders and Achilles-tendon pain was slight and conflicting, the review found. But in terms of tennis elbow, the shots seemed to actually be counterproductive. As Bill Vicenzino, Ph.D., the chairman of sports physiotherapy at the University of Queensland in Australia and senior author of the review, said in an e-mail response to questions, “There is a tendency” among tennis-elbow sufferers, “for the majority (70-90 percent) of those following a wait-and-see policy to get better” after six months to a year. But “this is not the case” for those getting cortisone shots, he said. They “tend to lag behind significantly at those time frames.” In other words, in some way, the cortisone shots impede full recovery, and compared with those “adopting a wait-and-see policy,” those getting the shots “are worse off.” Those people receiving multiple injections may be at particularly high risk for continuing damage. In one study that the researchers reviewed, “an average of four injections resulted in a 57 percent worse outcome when compared to one injection,” Dr. Vicenzino said.

This does not surprise me at all. Cortisone is an analog of cortisol, our stress hormone, which slows healing. This has been well-known for decades, yet doctors continue to shoot people up because they want the "quick fix".

Cortisol is also anti-inflammatory...but inflammation is your body's healing response. Yes, sometimes inflammation gets out of control and needs to be damped down, but only in certain limited situations.

I bet in about ten years they'll suddenly discover that icing tendon injuries is bad for the same reasons...because it inhibits circulation, and therefore healing. Once the immediate danger of swelling so severe that it cuts off blood circulation (or massive internal bleeding) is over, ice is massively counterproductive to healing.

Ice is only a temporary vasoconstrictor, the funny part is once you remove the ice the localized area has enhanced blood perfusion = Ice still good. like anything else the quick fix probably isn't the best long term repair option

This is old new isn't it ?? I've been told it's a bad procedure for years (15 or more). I considered it for an injury and was told by several docs not to do it because of Diminishing returns and potential damage to the injected area in the long run.

the wait and see group had 6-12 months of recovery because they were in pain.

the cortisone group had no pain and continued to do the same activity that caused the injury.

therefore,pain can be your friend

What jon gaper said, assuming they didn't control for the amount of playing post-treatment.

I had three in my tennis elbow that ended in surgery. I restrained my elbow in August and it is still tender. Fingers crossed.

I had three in my shoulder that ended in surgery.

Cortisone did get me through a golf trip to Ireland.

Anecdotal for me but I agree with the findings. Temporary fix..

It also causes bone to break down. When I had a severe case of medial epicondilitis (golfers elbow) I took a cortisone injection. A year later, still suffering, I saw a specialist. He took x-rays and asked me about my injection. I asked how he knew, and he pointed to a round spot, in the bone, and said this is what cortisone does.

Anyone know if cortisone patches have the same outcome?

Originally Posted by kingdom-tele

Ice is only a temporary vasoconstrictor, the funny part is once you remove the ice the localized area has enhanced blood perfusion = Ice still good

Greater than by applying heat? I'd like to see the studies on that. (not sarcasm)

Seems plausible from a distance. That said, meta-analysis is definitely not the most robust type of analysis.

http://en.wikipedia.org/wiki/Meta-analysis

Meta-analysis can never follow the rules of hard science, for example being double-blind, controlled, or proposing a way to falsify the theory in question. It is only a statistical examination of scientific studies, not an actual scientific study, itself.

A weakness of the method is that sources of bias are not controlled by the method. A good meta-analysis of badly designed studies will still result in bad statistics. Robert Slavin has argued that only methodologically sound studies should be included in a meta-analysis, a practice he calls 'best evidence meta-analysis'. Other meta-analysts would include weaker studies, and add a study-level predictor variable that reflects the methodological quality of the studies to examine the effect of study quality on the effect size.

Originally Posted by Spats

Greater than by applying heat? I'd like to see the studies on that. (not sarcasm)

Spats - not greater than heat necessarily, but there is still the component of vasodialation that occurs. old school, but still applicable "Vascular reactions of the human forearm to cold", Clinical Science, Vol 17, pp 165-79, 1958.

google Hunting Response, lymphatic response to ice, etc.

We primarily just do ice massage to avoid these.

Interestingly, we have seen people post direct injection of their own blood (only epicondylitis thus far) have great results.

Originally Posted by Spats

Greater than by applying heat? I'd like to see the studies on that. (not sarcasm)

your observation regrding ice is why following the initial swelling period, treatment are often ice/heat alternating

to clear things up about the ice, yes ice is a temporary vasoconstrictor and there will be some re-warming after ice application. However ice does some very important things in terms of acute injury and should be used exclusively in the acute phase. this generally lasts 3-4 day but can be extended in some cases, such as more severe injury, surgery, reaggivation of a subacute injury.

1. minimizes swelling
2. minimized swelling decreases the amount of secondary tissue death due to hypoxia and or presence of inflammatory chemicals
3. minimized swelling allows for earlier return to full motion
4. minimized swelling decreases pain and spasm
5. decreasing swelling and effusion maintains muscle function

After the initial 3-4 days after an acute injury heat is generally more beneficial. Unless there is periodic aggravation of the injury. i.e. exercising with a recent sub-acute injury. In this care heating before activity and icing after would be a good scenario. Typical ice application would be 15-20 min on with 1-2 hrs in between treatments, repeated as many times per day as is convenient/possible.

Typically it is ok to switch to heat after the acute phase is completed,
1. 3-4 days up to 5-7 days after initial injury
2. the area is not longer warmer to the touch than the contralateral side
3. pain and swelling have begun to decrease
4. no active swelling is present.
5. again in the sub-acute phase sometime heat before and ice after activity is a good practice.

Contrast-baths/treatments are ok in the subacute phase but not during the acute phase...ice only.

Once the injury is well into the chronic phase heat is generally the accepted treatment.

Use of heat does several things.
1. vasodilator
2. can help decrease stagnant swelling/effusion though increased local and or systmic circulation
3. promoted motion thought increased tissue extensability
4. helps flush out inflammatory chemicals and dead tissue through increased circulation
5. brings in oxygenated blood to help repair damaged tissue
6. help decrease pain and spasm

when you understand the inflammatory process choosing heat of ice application is not hard.

As far as my take on cortico-steriods:

They have their uses and I have seen lost of folks get better with their use, But they are a crap shoot. I've seen lots of folks not have any benefit from their use as well. With judicious use they can be helpful but repeated and prolonged use is not typically recommended.

Thanks Vinman . . . very helpful info . . . could you explain the following - is it bad to use ice longer than the 15 to 20 minutes??? If someone is immobile, and can use ice longer, provided it is not directly on skin, why would this not be good?

"Typical ice application would be 15-20 min on with 1-2 hrs in between treatments, repeated as many times per day as is convenient/possible."

Again, thanks.

Originally Posted by Vinman

when you understand the inflammatory process choosing heat of ice application is not hard.

Nice summary Vinman.

I would only add that if you are going to familiarize yourself with the inflammatory process the reader should also note the potential to enhance inflamm. with to much ice(dropping the tissue temp to low)

inflamm is not a bad thing, edema that doesn't get mobilized becomes the issue.

exactly, the inflammatory response is necessary for tissue healing to occur but is a process that can cause undue harm if left unchecked and or treated the wrong way.

As for the Hunting response, it was initially thought that ice application greater the 20-30 minutes creates a vasodilation effect. Basically the body's last ditch effort to re-warm itself. There is some discussion on this and as far as I know there is no conclusive evidence that this does or does not happen.

My general recommendation stands for most situations. 15-20 min at a time with 1-2 hrs in between applications. The 15-20 min time is below the Hunting response time frame and the 1-2 hr break allows the body to re-warm the area and prevent cold-induced injury.

This would be modified or contraindicated for people with poor circulation in the extremities, sensitivity to cold or with poor sensation in the area, conditions like diabetes and Renauds come into play here, as well as people with peripheral artery disease or neurological impairment. there could be others but those are the ones on the top of my head.

Also use of gel freezer packs should be used with some sort of thin cloth between the pack and the skin due to risk of frostbite. Ice bags can generally be applied directly to the skin without too much risk for folks without the above mentioned conditions.

Originally Posted by Vinman

Also use of gel freezer packs should be used with some sort of thin cloth between the pack and the skin due to risk of frostbite. Ice bags can generally be applied directly to the skin without too much risk for folks without the above mentioned conditions.

What about frozen peas? They're my preferred choice for icing.

Interesting news - I've had 1 in my elbow almost 5 years ago now. Pain was back 3 years ago and is just now as bad as it was when I had my first injection. I was planning on having another one, maybe I'll just start with a stim routine (I ice consistently).

the merits of frozen peas has not been studies enough. Great choice for icing bony parts. but might want to label them specifically for icing or just heat them up and eat them after using them.

Vin - I was curious how the frostbite risk compared to ice or gel packs.

gel packs freeze at a lower temp than water increasing the risk of frostbite. The presence of water while the ice melts indicates a temp greater than 32 deg reducing the risk of frostbite.

Ice bags still can cause cold induced injury but generally not in healthy folks with good neurological and vascular systems.

I have run across one or two folks with extreme sensitivity almost an allergic response to ice. instead of their skin being cold it gets hot swollen and itchy.

wish i had some cortisone...

don't mean to jack the thread, but does compression and elevation do anygood after the first day or two?